NHI will have some losers and win­ners

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The gov­ern­ment’s pro­posed Na­tional Health In­sur­ance (NHI) scheme aims to in­duce “mas­sive” re­struc­tur­ing of the pub­lic and pri­vate healthcare sec­tors that could see some cit­i­zens get­ting lower-qual­ity ser­vices than they cur­rently re­ceive from pri­vate prac­ti­tion­ers and hos­pi­tals.

There is also some risk that poor work­ers, ru­ral dwellers and farm labour­ers might re­ceive less eq­ui­table treat­ment un­der the NHI, which aims to pe­nalise pa­tients for by­pass­ing the re­fer­ral sys­tem, en­cour­ages the use of health fa­cil­i­ties close to home and doesn’t pro­vide for trans­port costs, which am­plify the high cost of ac­cess­ing healthcare for the poor.

The re­fer­ral sys­tem re­quires that pa­tients have to first present them­selves at a pri­mary healthcare fa­cil­ity or a con­tracted gen­eral prac­ti­tioner, for ex­am­ple, and then be re­ferred through the sys­tem to spe­cial­ists and hos­pi­tals.

Th­ese were among is­sues a panel of health ex­perts raised at a pub­lic dis­cus­sion held at the Univer­sity of KwaZulu-Natal, on whether the NHI white pa­per meets the hu­man rights ob­jec­tive of ac­cess to qual­ity healthcare en­shrined in the Con­sti­tu­tion.

Les­lie Lon­don of the Univer­sity of Cape Town’s School of Pub­lic Health and Fam­ily Medicine said there would be “win­ners and losers” un­der NHI.

“Some peo­ple ex­pect the NHI to de­liver the same amount of ser­vices they cur­rently get in pri­vate health ser­vices, but that will not hap­pen. They will get less,” he said. “The white pa­per is quiet on how the NHI is go­ing to deal with ra­tioning. A wor­ry­ing pro­vi­sion is the penal­ties for by­pass­ing [the re­fer­ral sys­tem] and en­cour­ag­ing peo­ple to use ser­vices near to where they are, which is to be con­trolled by some form of gate­keep­ing. Co­er­cion is anath­ema to a rights­based ap­proach to health.”

Lon­don said farm work­ers re­lied on farm­ers for trans­port to ac­cess healthcare and there was no men­tion of work­ers’ big­gest cost of trans­port to get to fa­cil­i­ties. “Un­less it is mapped out very clearly, it does risk in­creas­ing in­equal­ity,” Lon­don said.

Con­cern around how pa­tients’ med­i­cal in­for­ma­tion will be pro­tected from the big busi­ness of in­ter­na­tional trade in med­i­cal data was an­other is­sue Lon­don raised.

Depart­ment of health deputy di­rec­tor­gen­eral of health, reg­u­la­tion and com­pli­ance man­age­ment, An­ban Pil­lay, said at present ac­cess to healthcare was based on house­holds’ so­cioe­co­nomic sta­tus, but un­der the NHI there would be no out-of-pocket pay­ments at the point of treat­ment.

“At present, those with a higher so­cioe­co­nomic sta­tus have the great­est ac­cess, and those with the least wealth have the great­est need, but the least ac­cess. There needs to be mas­sive re­or­gan­i­sa­tion of both pub­lic and pri­vate healthcare. The young and healthy should sub­sidise the sick and old,” Pil­lay said.

The NHI white pa­per draws sev­eral il­lus­tra­tions that ex­plore pos­si­ble fund­ing meth­ods, which in­clude rais­ing in­come tax lev­els in­cre­men­tally over a few years or by rais­ing a pay­roll levy sim­i­lar to the cur­rent skills devel­op­ment levy, rais­ing VAT, or us­ing all three tax col­lec­tion meth­ods.

“It is clearly a so­cial in­vest­ment, it is not some­thing you are go­ing to in­vest in to gain some prof­its,” he said.

Once fully im­ple­mented, NHI ben­e­fits would in­clude what was cov­ered by the Com­pen­sa­tion for Oc­cu­pa­tional In­juries and Dis­eases Act, the Road Ac­ci­dent Fund, Un­em­ploy­ment In­sur­ance Fund and Work­men’s Com­pen­sa­tion Act, Pil­lay said.

Pil­lay said the NHI would im­prove labour pro­duc­tiv­ity, and Asian coun­tries, which had im­ple­mented sim­i­lar schemes, had also shown “mas­sive in­creases” in GDP growth.

Foun­da­tion for Hu­man Rights deputy di­rec­tor Hanif Vally said re­search had shown that the more un­equal a so­ci­ety, the more ad­verse so­cial sit­u­a­tions it faced, in­clud­ing health prob­lems such as homi­cide and obe­sity.

He said the NHI would pro­mote eq­uity in ac­cess­ing healthcare ser­vices and so­cial co­he­sion.

“Dignity is an es­sen­tial value of so­ci­ety, but when peo­ple live in poverty, there is no dignity, so we are in vi­o­la­tion of hu­man rights all the time. The rea­son peo­ple are poor is they lack ca­pa­bil­i­ties such as the right to hous­ing, food and health,” he said.

Vally said only be­tween 18% and 20% of peo­ple had med­i­cal aid in South Africa, but more than 50% of doc­tors and even more spe­cial­ists ser­viced them.

Health Pro­fes­sions Coun­cil of SA pres­i­dent Kgosi Let­lape called for med­i­cal schemes to be scrapped, say­ing around 3 000 to 4 000 med­i­cal prac­ti­tion­ers cur­rently worked in the in­dus­try.

He said NHI could not co­ex­ist with med­i­cal schemes, which were a “crime against hu­man­ity” for ex­clud­ing the poor and caus­ing a brain drain from the pub­lic sec­tor.

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